HomeMy WebLinkAboutWAT Application - 6/17/1997 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
gnpironmantar Ha>rth
uli.rth
PO BOX 1666 SHBLTON WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination Of Adequacy TOLL FREE 1-Boo-562-5628FAX(360)427-7798
Instructions
1 CamplaeR
att 1:No examinant 3�fiyh..na»�»Iae�L
2. ' t".ompleteonty rUb',PorilOnafPMt7.spplymg.W 4he typeofwalcrayai®atdrliEzeA.
3. Subtniteo leas[. IteatWa.wtRtasardrmeatsfdihaheal9t lotreviato.
PART 1: Appliccay/nt'fParcel Identification
Name of Applicant / '11A l 5!s Datea
,=cNc; Ku'SS` Telephone ?74, 3L77
Mailing Address
Assessor's Parcel Number J4 054
e of Water stem Check One : Reason or A licadon Check One :
PubBa/CotS®unity Water System(2 a mac Building pamit
e l ❑ Land use application,if so..
❑ Individual water Source(e1e camas..),if so.. ❑ Division of hmd
❑ well k of Parcelsl
❑ spring/surface water SPI-I9=
❑ other(��) ❑ Boundary line adjjuusttmenntt j}��
�,(( Other(explun)�i'==y'—
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water System _
Name of Water System
Water Facility Inventory(WFI)Number:
❑ The water purveyor has filed a letter gran ing blanket hookups to this watat system.
❑ I am prwe the menage of thiswata system. The water system has been approved for services. There are
oanoxh,,,muse. This will be the connection. water system E able and
wiese
llinadyg to pm�waleto aids(these)connections wilhoul ex�6 the limits of the water system or any limits
set by state and toed regulation.
Signature of Water System Manager
Date
H:IWDATA�ffr WATFRAr33.Wr Update b.,20,1"5
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MASON COUNTY
QEPARTMENT OF HEALTH SERVICE5
Emawinental Heolth
Persona(Xeatth
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275A467&4468
Application for Determination of Adequacy 15
Instructions 7
I Can P a4m# T<aelumutdi cacao be fate gnat Part3 t }3ilr )nIL
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Ltatio ;uYlihatththamentb lathe heatihd """birci ze "
PART 1: Applicant/Parcel Identification
Name of Applicant_ _�4 ! /; �4 v Linn Date �2 9,
Mailing Address NL 9 Dom- o s S o / V&/ Telephone
9us� u
Assessor's Parcel Number 3S2 - 5-r o
o Water stem Check One : Reason or lication Check one):
O Public/Community Water System(2 or ton [01L�wd
ng permit
cormeaionr) seIndividual water source(ooe wrmecuon),if se.. ivision ofl ifso..
o WellDivision of lend
o Spring/surfece water #of Parcels?SPH90 Oter(explain) Boundary line adjustment
Other(explain) 1
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water System
Name of Water System 13 lit ✓ 11t L± 114
Water Facility Inventory(WFI)Number: _ e 5-35'00
O The water purveyor has filed a letter granting blanket hookups to this water system.
I am the manager of this water system. The water system has been approved for Sy0 services. There are
presently connectiore m use. This will h the connection. lbu water system is able and
willinglimits
sett provt by sitea and Inc water to this Otte c an
limits set wr outTi t exceeding the limits of the water"am or any
al regu ati
Signature of Water System ManagerE Date /jam-�
n IWA17-A URCHIMWAIMM.WP Updw:March 72,1999
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